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EXHIBIT NO.4
FORM OF THE VARIABLE ANNUITY CONTRACT
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NATIONWIDE LIFE AND ANNUITY INSURANCE CO.
P.O. BOX 182008
COLUMBUS, OHIO 43218-2008
Dear Policyowner:
PLEASE READ YOUR CONTRACT CAREFULLY
This is a legal contract between the Owner and Us.
This Contract is provided in return for:
(1) the application, which is a part of this Contract; and
(2) receipt of the Initial Purchase Payment.
To be sure the Owner is satisfied with this Contract, he/she has ten days to
examine it and return it for any reason. This ten day period begins when the
Owner receives the Contract. If the Owner returns this Contract to the Home
Office of the Company during this ten day period, the Company will return the
Purchase Payment Value (as of the date of cancellation) without deduction for
any sales charges or administration fees. (The Company reserves the right to
return Contract Value where permitted by state law).
Thank you for relying on Us.
If you have any questions about your Contract or need more assistance contact
your agent or our home office.
Executed for the Company on the Date of Issue.
READ YOUR CONTRACT CAREFULLY
PLEASE NOTE - ANNUITY PAYMENTS AND OTHER VALUES PROVIDED BY THIS CONTRACT, WHEN
BASED ON THE INVESTMENT EXPERIENCE OF A SEPARATE ACCOUNT ARE VARIABLE, MAY
INCREASE OR DECREASE IN ACCORDANCE WITH THE NET INVESTMENT FACTOR, AND ARE NOT
GUARANTEED AS TO A FIXED DOLLAR AMOUNT.
NOTICE: Details for the variable provisions in the contract may be found on
pages 10, 14, and 15.
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT DEFERRED VARIABLE ANNUITY,
NON-PARTICIPATING
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CONTENTS
Page
Cover Page.....................................................................1
Table of Contents..............................................................2
Data Page......................................................................3
Definitions....................................................................4
General Provisions.............................................................6
Required Distributions and Death Benefit.......................................8
Accumulation Provisions........................................................9
Surrender Provisions..........................................................13
Annuitization Provisions......................................................15
Annuity Payment Options.......................................................16
Annuity Tables................................................................19
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DATA PAGE
OWNER XXXXXX XXXXX
JOINT OWNER (if any)
ANNUITANT XXXXXX XXXXX
BENEFICIARY AS REFERENCED ON APPLICATION
UNLESS CHANGED
CONTINGENT BENEFICIARY (if any) AS REFERENCED ON APPLICATION
UNLESS CHANGED
CONTRACT NUMBER 07881811
AGE AND SEX OF ANNUITANT 17
FEMALE
ISSUE DATE JULY 27, 1994
INITIAL PURCHASE PAYMENT $1,050.00
ANNUITY COMMENCEMENT DATE AUGUST 01, 2052
Contract Owners may have Purchase Payments applied to the general Account
of Nationwide Life and Annuity Insurance Company or towards the purchase of
shares at net asset value of the following funds:
FIDELITY VARIABLE INS. PRODUCTS FUND -
*Equity-Income Portfolio (FEIP)
*Overseas Portfolio (FOP)
NATIONWIDE SEPARATE ACCOUNT TRUST -
*Money Market Fund (MMF)
*Total Return Fund (TRF)
THE ONE GROUP INVESTMENT TRUST -
*Asset Allocation Fund (OGAA)
*Government Bond Fund (OGGB)
*Large Company Growth Fund (OGLG)
*Small Company Growth Fund (OGSG)
FOR USE WITH NATIONWIDE LIFE AND ANNUITY VA SEPARATE ACCOUNT 3
A SEPARATE INVESTMENT ACCOUNT SPECIALLY
ESTABLISHED FOR INVESTMENT IN THE ABOVE FUNDS
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DEFINITIONS
THE COMPANY The Company is Nationwide Life and
Annuity Insurance Company.
ACCUMULATION UNIT An accounting unit of
measure used to calculate the Variable
Account Contract Value prior to the
Annuity Commencement Date.
ANNUITANT The person named on the Data Page on
whose life this Contract is issued and
who will receive annuity payments
beginning within 10 working days of the
Annuity Commencement Date. The
Annuitant, if someone other than the
Owner, becomes the Owner of the Contract
on the Annuity Commencement Date. The
Company reserves the right to reject any
change of the Annuitant which has been
made without the prior consent of the
Company.
ANNUITY COMMENCEMENT DATE The date on which
annuity payments are scheduled to
commence. The Annuity Commencement Date
is shown on the Data Page. This date may
be changed by the Owner prior to the
date annuity payments actually commence.
Annuity Payments will begin no later
than 10 working days after the Annuity
Commencement Date.
ANNUITY PAYMENT OPTION The method for making
annuity payments. The Annuity Payment
Option selected on the application may
be changed by the Owner prior to the
Annuity Commencement Date.
ANNUITY UNIT An accounting unit of measure used
to calculate the value of Variable
Annuity payments.
BENEFICIARY The Beneficiary named in the application
to receive certain benefits under this
Contract when the Annuitant dies.
CONTINGENT BENEFICIARY The person named in the
application to be the Beneficiary if the
named Beneficiary is not living when the
Annuitant dies.
CONTRACT ANNIVERSARY An anniversary of the
Contract Issue Date as shown on the
Data Page.
CONTRACT OWNER (OWNER) The Contract Owner is the person who
possesses all rights under the Contract,
including the right to designate and
change any designations of the
Beneficiary, Contingent Beneficiary,
Annuity Payment Option, and the Annuity
Commencement Date. The Owner is the
person named in the application, unless
changed. Please see "Contract Ownership"
and "Joint Ownership" on pages 6 and 7.
CONTRACT VALUE The sum of the Variable Account Contract
Value and the Fixed Account Contract
Value.
CONTRACT YEAR Each year starting with either the
Date of Issue or a Contract Anniversary.
DATE OF ISSUE The Date shown as the Date of Issue on
the Data Page of the Contract.
DISTRIBUTION Any payment of part or all of the
Contract Value.
FIXED ACCOUNT All assets of the Company other than
those in any segregated asset account.
FIXED ANNUITY An annuity providing for payments which
are guaranteed by the Company as to
dollar amount during the annuity payment
period.
HOME OFFICE The main office of the Company located
in Columbus, Ohio.
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JOINT OWNER The Joint Owner, if any, possesses an
undivided interest in the entire
Contract in conjunction with the Owner.
Please see "Contract Ownership" and
"Joint Ownership" on pages 6 and 7.
NON-QUALIFIED CONTRACT A Contract issued to fund a
Non-Qualified Plan.
NON-QUALIFIED PLAN A retirement program which does not
receive favorable tax treatment under
the provisions of the Internal Revenue
Code.
PURCHASE PAYMENT ANNIVERSARY An anniversary of the date a purchase
payment is made under the Contract.
PURCHASE PAYMENT YEAR Any year commencing with the date a
purchase payment is made.
QUALIFIED CONTRACT A Contract issued to fund a
Qualified Plan.
QUALIFIED PLAN A retirement program which receives
favorable tax treatment under the
provisions of the Internal Revenue Code.
VALUATION DATE Each day the New York Stock Exchange and
the Company's Home Office are open for
business or any other day during which
there is a sufficient degree of trading
of the Variable Account's mutual fund
shares that the current net asset value
of its Accumulation Units might be
materially affected.
VALUATION PERIOD The period of time commencing at
the close of business of the New York
Stock Exchange and ending at the close
of business for the next succeeding
Valuation Date.
VARIABLE ACCOUNT A separate investment account of the
Company into which Variable Account
purchase payments are allocated.
VARIABLE ANNUITY An annuity providing for payments which
vary in amount with the investment
experience of the Variable Account.
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GENERAL PROVISIONS
CHARGES The Company deducts a charge for the
administration of the Contract. This charge
is designed only to reimburse the Company
for any expense incurred that relates to the
administration of the Contract. The Company
will monitor this charge to ensure that it
does not exceed any accumulated expense. The
Contract Administration Charge is assessed
daily through the unit value calculation,
equal to an annual rate of [0.05%].
DEDUCTIONS FOR PREMIUM TAXES The Company will deduct from the Contract
Value the amount of any premium taxes levied
by a state or any other governmental entity.
At present, premium taxes imposed by certain
states range from .50% to 3.0%. The Company
currently deducts from the Contract Value
the applicable amount of premium taxes
levied at the time the Contract is
annuitized, except in those states which
require such taxes to be paid when incurred.
EXPENSE RISK CHARGE The Company will not increase charges for
administration of the Contract regardless of
its actual expenses. For assuming this
expense risk, the Company assesses an
Expense Risk Charge through the daily unit
value calculation which is equal to an
annual rate of [0.45%].
MORTALITY RISK CHARGE The Company assumes a "mortality risk" that
variable annuity payments will not be
affected by the death rates of persons
receiving such payments or of the general
population by virtue of annuity rates
incorporated in the Contract which cannot by
changed. For assuming this mortality risk,
the Company deducts a Mortality Risk Charge
through the daily unit value calculation,
which is equal to an annual rate of [0.80%].
BENEFICIARY PROVISIONS The Beneficiary and any Contingent
Beneficiary are named in the application,
unless changed. If the Beneficiary dies
prior to the Annuitant, the Contingent
Beneficiary becomes the Beneficiary. Unless
the Owner has provided otherwise, when there
are two or more Beneficiaries, they will
receive equal shares. If there is no named
Beneficiary or Contingent Beneficiary upon
the Annuitant's death, the Owner (or the
estate of the Owner, if the Annuitant is the
Owner) will be deemed to be the Beneficiary.
The Company may pay the commuted value of
any remaining unpaid payments to the estate.
Subject to the terms of any existing
assignment, the Owner may name a new
Beneficiary or a new Contingent Beneficiary
at any time during the lifetime of the
Annuitant. Any new choice of Beneficiary or
Contingent Beneficiary will automatically
revoke any prior choice of Beneficiary or
Contingent Beneficiary. Any change must be
made in writing and recorded at the Home
Office. The change will become effective as
of the date the written request is signed,
whether or not the Annuitant is living
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at the time of recording. A new choice of
Beneficiary or Contingent Beneficiary will
not apply to any payment made or action
taken by the Company prior to the time it
was received.
CONTRACT OWNERSHIP The Owner has all rights under the Contract,
unless otherwise provided. If the purchaser
names someone other than himself as Owner,
the purchaser would have no rights under the
Contract. The Owner is the person named in
the application, unless changed. The
Annuitant, if someone other than the Owner,
becomes the Owner on the Annuity
Commencement Date. If the Owner dies, a
Distribution will be made in accordance with
the Death of Contract Owner provision,
unless the recipient of the Distribution is
the Owner's spouse, in which case a
Distribution may be paid or the Contract may
continue, depending on the election of the
surviving spouse.
The Owner may name a new Owner at any time.
Any new choice of Owner will automatically
revoke any prior choice of Owner. Any
request for change must be made in writing
and received at the Home Office. The request
for change must be a "Proper Written
Application". The change will become
effective as of the date the written request
is signed. A new choice of Owner or
Contingent Owner will not apply to any
payment made or action taken by the Company
prior to the time it was received.
A request for change in the Annuitant,
Beneficiary, or Contingent Beneficiary must
be made by the Owner in writing on a form
acceptable to the Company. Any such change
is subject to approval by the Company.
JOINT OWNERSHIP If a Joint Owner is named in the
application, then the Owner and Joint Owner
will share an undivided interest in the
entire Contract. If the Owner and Joint
Owner wish to exercise Ownership rights in
the Contract independently of each other, it
must be so indicated in the application.
Otherwise, when an Owner and Joint Owner
have been named, the Company will only honor
requests for changes and the exercise of
other ownership rights that are made by both
the Owner and Joint Owner. When a Joint
Owner has been named, all references to
"Owner" or "Contract Owner" throughout this
Contract should be construed to mean both
the Owner and Joint Owner, unless otherwise
provided.
Where the Contract is issued to fund a
retirement plan entered into pursuant to
Section 408 of the Internal Revenue Code,
all the terms of this Contract and the
rights of the Owner, Joint Owner and
Annuitant may be subject to the Plan
Document.
ALTERATION OR MODIFICATION All changes to the terms of this Contract
must be made in writing and must be signed
by the President or Secretary of the
Company. No other person may change or alter
any of the terms or conditions of the
Contract.
ASSIGNMENT Unless otherwise provided, the Owner may
assign all rights under this Contract at any
time during the lifetime of the Annuitant,
prior to the Annuity Commencement Date. The
Company will not be bound by any assignment
until written notice is received and
recorded at the Home Office. The Company is
not responsible for the validity of any
assignment. An assignment will not apply to
any payment made or action taken by the
Company prior to the time it was recorded.
If this Contract is a Non-Qualified
Contract, the value of any portion of the
Contract which is assigned or pledged, may
be treated like a cash withdrawal for
federal tax purposes.
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If this Contract is issued to fund a
retirement plan pursuant to Internal Revenue
Code Section 408, it may not be assigned,
pledged or otherwise transferred except as
allowable by applicable law.
ENTIRE CONTRACT This document is an annuity contract between
the Owner and the Company. This Contract,
Annuity Application, Data Page, and
Supplementary Agreement (if applicable) make
up the Entire Contract.
MISSTATEMENT OF AGE OR SEX If the age or sex of the Annuitant has been
misstated, all payments and benefits under
this Contract will be adjusted. Payments and
benefits will be made, based on the correct
information. Proof of age of an Annuitant
may be required at any time, on a form
satisfactory to the Company. When the age or
sex of an Annuitant has been misstated, the
dollar amount of any overpayment will be
deducted from the next payment or payments
due under this Contract. The dollar amount
of any underpayment made by the Company as a
result of any such misstatement will be paid
in full with the next payment due under this
Contract.
EVIDENCE OF SURVIVAL Where any payments under this Contract
depend on the recipient being alive on a
given date, proof that such person is living
may be required by the Company.
PROTECTION OF PROCEEDS Payments under this Contract are not
assignable by any Beneficiary prior to the
time they are due. Payments are not subject
to the claims of creditors or to legal
process, except as mandated by applicable
laws.
REPORTS At least once each year prior to the Annuity
Commencement Date, a Report showing the
Contract Value will be provided to the
Owner.
INCONTESTABILITY This Contract will not be contested.
CONTRACT SETTLEMENT The Company may require this Contract to be
returned to the Home Office prior to making
any payments. All sums payable to or by the
Company under this Contract are payable at
the Home Office.
NUMBER AND GENDER Unless otherwise provided, all references in
this Contract which are in the singular form
will include the plural; all references in
the plural form will include the singular;
and all references in the male gender will
include the female gender.
NON-PARTICIPATING This Contract is non-participating. It will
not share in the surplus of the Company.
CONTRACT VALUE All values equal or exceed those required
under state law.
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REQUIRED DISTRIBUTIONS AND DEATH BENEFIT
Rules applicable for Contracts not issued in connection with a qualified plan or
individual retirement account.
DEATH OF CONTRACT OWNER If the Contract Owner (or Joint Owner): (a)
has named someone other than himself as
Xxxxxxxxx, and (b) dies prior to the Annuity
Commencement Date, a Distribution made in
accordance with Section 72(s) of the
Internal Revenue Code will be paid.
The recipient of the Distribution will be
any surviving Joint Owner. If there is no
Joint Owner, the distribution will be paid
to the Annuitant. If the deceased Owner or
Joint Owner is also the Annuitant, the
Distribution will be paid to the Beneficiary
(see "Death of Annuitant").
The Distribution will be paid within 5 years
of the Owner's death, unless: (a) the
recipient of the Distribution elects, within
one year of the Owner's death, to receive
the Distribution in the form of a life
annuity or an annuity for a period certain
not exceeding the recipient's life
expectancy; or (b) the recipient of the
Distribution is the Owner's spouse, in which
case, the Contract may be continued by the
surviving spouse as Contract Owner.
DEATH OF ANNUITANT If the Annuitant dies prior to the Annuity
Commencement Date, a Death Benefit will be
paid to the Beneficiary upon receipt of
proof of death of the Annuitant. The death
benefit will be paid as rapidly as under the
Annuity Payment Option elected by the Owner
and in effect at the time of the Annuitant's
death.
If the Owner or Joint Owner is also the
Annuitant, the death of such person will be
treated as the death of the Annuitant. If
such person dies prior to the Annuity
Commencement Date, the death benefit payable
to the Beneficiary will be paid in
conformance with the distribution provisions
set forth in the "Death of Contract Owner"
section of the contract.
GENERAL DEATH BENEFIT PROVISION The value of the Death Benefit will be
determined as of the Valuation Date on or
next following the date both proof of death,
and an election of single sum settlement or
Annuity Payment Option, are received in good
order by the Company.
The amount of the Death Benefit will be the
greater of: (1) the sum of all purchase
payments, less surrenders, or (2) the
Contract Value. The amount of the Death
Benefit will be limited to the Contract
Value if the Annuity Commencement Date is
deferred beyond age 75 of the Annuitant and
the Annuitant dies after attaining such age.
If a single sum settlement is requested,
payment will be made in accordance with any
applicable laws and regulations governing
the payment of Death Benefits. If an Annuity
Payment Option is desired, election may be
made by the Beneficiary during the 90 day
period beginning on the date written notice
is received by the Company. If no election
has been made by the end of such 90 day
period, the Death Benefit will be paid to
the Beneficiary in a single sum.
Contracts issued in connection with
Qualified Plans or individual retirement
accounts will be subject to specific rules
set forth in the Plan or Contract concerning
distributions upon death of the Annuitant.
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ACCUMULATION PROVISIONS
FLEXIBLE PURCHASE PAYMENTS This Contract is bought for: (1) the Initial
Purchase Payment; and (2) purchase payments
made after the first, if any. The cumulative
total of all purchase payments under this
and any other annuity contract(s) issued by
the Company having the same Annuitant may
not exceed $1,000,000 without the prior
consent of the Company.
INITIAL PURCHASE PAYMENT The Initial Purchase Payment is due on the
Date of Issue. The Initial Purchase Payment
may not be less than $5,000 for
Non-Qualified Contracts. However, if
periodic payments are expected by the
Company, this Initial Purchase Payment may
be satisfied by purchase payments made on an
annualized basis. For Qualified Contracts
issued pursuant to a retirement plan which
receives favorable tax treatment under the
provisions of Section 408 of the Internal
Revenue Code; the minimum purchase payment
is $2,000. However, if periodic payments are
expected by the Company, the Company will
accept purchase payments which, on an
annualized basis, are at least $2,000 for
the first Contract Year. Purchase Payments,
if any, after the first Contract Year must
be at least $10 each. The Company reserves
the right to reject any Purchase Payment
which does not meet this minimum payment
requirement.
NO DEFAULT There are no penalties for failure to
continue Purchase Payments. Unless
surrendered for the full Contract Value, the
Contract will continue in full force until
the Annuity Commencement Date. This Contract
will not be in default, even if no
additional purchase payments are made after
the first.
CHANGE IN PURCHASE PAYMENTS The Owner is not obligated to continue
Purchase Payments. The Owner may: (1)
increase or decrease the amount of Purchase
Payments, subject to any minimum payment
requirements; (2) change the frequency of
Purchase Payments. A change in the frequency
or amount of Purchase Payments does not have
to be made by written request.
ALLOCATION OF PURCHASE PAYMENTS The Owner elects to have the Purchase
Payments allocated among the Fixed Account
and the Sub-Accounts of the Variable Account
at the time of application.
CONTRACT VALUE The Contract Value at any time will be the
sum of: (1) the Variable Account Contract
Value; and (2) the Fixed Account Contract
Value.
FIXED ACCOUNT The Fixed Account Contract Value at any time
will be: (1) the sum of all amounts credited
to the Fixed Account under this Contract;
plus (2) interest credited to the Fixed
Account; less (3) any amounts canceled or
withdrawn for charges, deductions, or
Surrenders.
INTEREST TO BE CREDITED The Company will credit interest to the
Fixed Account Contract Value. Such interest
will be credited at such rate or rates as
the Company prospectively declares from time
to time. Such rates will be declared to the
Owner in writing prior to each quarterly
period. Any such rate or rates so
determined, for which deposits are received,
will remain in effect for a period of not
less than 12 months. However, the Company
guarantees that it will credit interest at
not less than 3.0% per year.
VARIABLE ACCOUNT CONTRACT VALUE The Variable Account Contract Value is the
sum of the value of all Variable Account
Accumulation Units under this Contract. If:
(1) part or all of the Variable Account
Contract Value is surrendered, or (2) when
charges or deductions are made against the
Variable Account Contract Value then, an
appropriate number of Accumulation Units
will be canceled or surrendered to equal
such amount.
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THE VARIABLE ACCOUNT The Variable Account is a separate
investment account of the Company. It is
named on the Data Page. The Company has
allocated a part of its assets for this
Contract and certain other contracts to the
Variable Account. Such assets of the
Variable Account remain the property of the
Company. However, they may not be charged
with the liabilities from any other business
in which the Company may take part.
INVESTMENTS OF THE VARIABLE ACCOUNT The purchase payments applied to the
Variable Account will be invested at net
asset value in one or more of the mutual
funds shown on the Data Page.
SUB-ACCOUNTS The Variable Account is divided into
Sub-Accounts which invest in shares of
mutual funds. Purchase payments are
allocated among one or more of these
Sub-Accounts, as designated by the Owner.
VALUATION OF ASSETS Mutual fund
shares in the Variable
Account will be valued at
their net asset value.
VARIABLE ACCOUNT ACCUMULATION UNITS The number of Accumulation Units for each
Sub-Account of the Variable Account is found
by dividing: (1) the net amount allocated to
the Sub-Account; by (2) the Accumulation
Unit value for the Sub-Account for the
Valuation Period during which the Company
received the Purchase Payments.
VARIABLE ACCOUNT The value of an Accumulation Unit for each
Sub-Account of the Variable Account was
arbitrarily set at $10 when the first mutual
fund shares were bought. The value for any
later Valuation Period is found as follows:
The Accumulation Unit value for each
Sub-Account for the last prior Valuation
Period is multiplied by the Net Investment
Factor for the Sub-Account for the next
following Valuation period. The result is
the Accumulation Unit Value. The value of an
Accumulation Unit may increase or decrease
from one Valuation Period to the next. The
number of Accumulation Units will not change
as a result of investment experience.
NET INVESTMENT FACTOR The Net Investment Factor is an index
applied to measure the investment
performance of a Sub-Account from one
Valuation Period to the next. The Net
Investment Factor may be greater or less
than one; therefore, the value of an
Accumulation Unit may increase or decrease.
The Net Investment Factor for any
Sub-Account for any Valuation period is
determined by: dividing (1) by (2) and
subtracting (3) from the result, where:
1. is the net result of:
a. the net asset value per share of the
mutual fund held in the Sub-Account,
determined at the end of the current
Valuation Period; plus
b. the per share amount of any dividend
or capital gain distributions made by
the mutual fund held in the Sub-
Account, if the "ex-dividend" date
occurs during the current Valuation
Period; plus or minus
c. a per share charge or credit for any
taxes reserved for, which is determined
by the Company to have resulted from the
investment operations of the
Sub-Account.
2. is the net result of:
a. the net asset value per share of the
mutual fund held in the Sub-Account,
determined at the end of the last prior
Valuation period; plus or minus
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b. the per share charge or credit for
any taxes reserved for the last prior
Valuation Period.
3. is a factor representing the Mortality
and Expense Risk Charge and the
Administration Charge deducted from the
Variable Account. Such factor is equal, on
an annual basis, to 1.30% of the daily net
asset value of the Variable Account.
For funds that credit dividends on a daily
basis and pay such dividends once a month,
the Net Investment Factor allows for the
monthly reinvestment of these daily
dividends.
FIXED ACCOUNT PROVISIONS The Fixed Account is the general account of
the Company. It is made up of all assets of
the Company other than: (1) those in the
Variable Account; and (2) those in any other
segregated asset account.
TRANSFER PROVISIONS The Owner may annually transfer a portion of
the value of the Fixed Account to the
Variable Account and a portion of the
Variable Account to the Fixed Account
without penalty or adjustment. Transfers
from the Fixed Account to the Variable
Account will be determined by the Company,
but will not be less than 10%, and will be
declared before the termination date of the
then current interest rate guarantee period.
(The Company will always allow 10% of the
Fixed Account value to be transferred to the
Variable Account.) Transfers from the Fixed
Account must be made within 30 days after
the termination date of the guaranteed
period.
The Owner may request a transfer of up to
100% of the Contract Value from the Variable
Account to the Fixed Account. Such transfers
must be made prior to the Annuity
Commencement Date or the death of the
Annuitant. No such transfers will be
permitted prior to the first Contract
Anniversary or within 12 months of any
previous transfer. The Owner's value of each
sub-account will be determined as of the day
the written request for transfer is received
in good order at the Home Office of the
Company. The Company reserves the right to
restrict transfers to the Fixed Account to
25% of the Contract Value, depending on
market conditions at the time of transfer.
Transfers from the Fixed Account may not be
made prior to the first Contract Anniversary
or within 12 months of any prior Transfer.
Transfers must also be made prior to the
Annuity Commencement Date.
DISTRIBUTION PROVISIONS The following events will give rise to a
Distribution:
1. Reaching the Annuity Commencement
Date -- Distribution will be made
pursuant to the Annuity Payment
Option selected.
2. Death of the Annuitant prior to the
Annuity Commencement Date --
Distribution to be made in accordance
with the options available under the
Death of Annuitant provision of this
Contract.
3. Death of the Contract Owner --
Distribution to be made in a manner
consistent with the "Death of
Contract Owner" provisions of this
Contract.
4. Surrender -- Distribution to be made
in accordance with the Surrender
provisions of the Contract.
5. In accordance with Section 72 of the
Federal Internal Revenue Code, if a
non-natural person is the Owner, any
change in the primary annuitant will
be treated as the death of the Owner.
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EXCHANGE PRIVILEGES The Contract Owner may exchange this
Contract for an annuity contract which:
(1) is issued by the Company; and (2) is
determined by the Company to be the type
and class eligible for such exchange. In
determining which contracts may be of
the same type and class as this
Contract, the Company shall apply its
rules and regulations applicable
thereto.
The Contract Owner must request an
exchange: (1) in writing; and (2) at
least 45 days prior to the Annuity
Commencement Date. Any such exchange
shall be made free from any Contingent
Deferred Sales Charge provided for in
this Contract.
SURRENDER PROVISIONS
GENERAL SURRENDER PROVISIONS The Owner may Surrender part or all of
the Contract Value at any time this
Contract is in force and prior to the
earlier of the Annuity Commencement Date
or the death of the Annuitant. For the
purpose of calculating the Contingent
Deferred Sales Charge, and in order to
minimize the applicable Contingent
Deferred Sales Charge, all amounts
withdrawn are deemed to be withdrawn on
the first-in first-out basis i.e., all
withdrawals are deemed to come from the
oldest Purchase Payments first.
(Note--for tax purposes, withdrawals may
be treated differently.) All Surrenders
will have the following conditions:
1. The request for Surrender must be in
writing.
2. The Surrender Value will be paid to
the Owner when proper written
application and the Contract are
received at the Home Office.
3. Payment of the Variable Account
Contract Value will be made within
seven days of receipt of both proper
written application and the Contract.
Payment of the Fixed Account Contract
Value may be deferred up to six
months following receipt of
application.
4. When written application and the
Contract are received, the Company
will Surrender a number of Variable
Account Accumulation Units and an
amount from the Fixed Account needed
to equal: (a) the dollar amount
requested; plus (b) any Contingent
Deferred Sales Charge which applies.
5. Unless the Owner has instructed
otherwise, if a partial Surrender is
requested, the Surrender will be made
as follows: (a) from the Variable
Account Contract Value; and (b) from
the Fixed Account Contract Value. The
amounts surrendered from the Fixed
Account and Variable Account, will be
in the same proportion that the
Owner's interest in the Fixed Account
and Variable Account bears to the
total Contract Value.
CONTINGENT DEFERRED If part or all of the Contract Value is
surrendered, a Contingent Deferred Sales
Charge may be applied at the time of a
surrender. The Contingent Deferred Sales
Charge will be equal to no more than 7%
of the lesser of: (1) the total of all
purchase payments made within 84 months
prior to the date of the request for
Surrender; or (2) the amount
surrendered.
In no event will the cumulative total of
all Contingent Deferred Sales Charges
exceed 7% of the total purchase payments
made within 84 months prior to the date
of the request for Surrender.
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The Contingent Deferred Sales Charge applies to purchase payments as follows:
Years From Date Of Sales Charge
Purchase Payment Percentage
---------------- ----------
[0 7%
1 6%
2 5%
3 4%
4 3%
5 2%
6 1%
7 0%]
A Contingent Deferred Sales Charge will
not be assessed against any values which
have been held under the Contract for at
least 84 months or any values applied to
purchase an annuity.
REDUCTION OF CONTINGENT The amount of Contingent Deferred Sales
DEFERRED SALES CHARGE Charges on the Contracts may be reduced
when sales of the Contracts are made to
a trustee, employer or similar entity
pursuant to a retirement plan or when
sales are made in a similar arrangement
where offering the Contracts to a group
of individuals under such a program
results in savings of sales expenses.
The entitlement to such a reduction in
Contingent Deferred Sales Charges will
be determined exclusively by the
Company.
SURRENDERS WITHOUT CHARGE Once each year, starting with the second
Purchase Payment Year of a Purchase
Payment, the Owner may Surrender,
without a Contingent Deferred Sales
Charge, an amount equal to 10% of the
purchase payment at the time of
surrender. This free withdrawal
privilege is non-cumulative and must be
used in the year available.
After a Purchase Payment's seventh
Purchase Payment Anniversary, the Owner
may surrender without charge: (1) 100%
of the purchase payment amount, less (2)
any amount of the purchase payment
previously surrendered.
SURRENDER VALUE The Surrender Value is the amount that
will be paid if the full Contract Value
is surrendered. The Surrender Value at
any time will be:
1. The Contract Value; less
2. Any Contingent Deferred Sales Charge
which applies.
PARTIAL SURRENDERS In the event of a Partial Surrender, the
Company will, unless instructed to the
contrary, surrender Accumulation Units
from all Sub-Accounts in which the
Contract Owner has an interest and from
the Fixed Account. The number of
Accumulation Units surrendered from each
such Sub-Account and the amount
surrendered from the Fixed Account will
be in the same proportion that the
Contract Owner's interest in these
Sub-Accounts and Fixed Account bears to
the total Contract Value.
DELAY IN PAYMENT OR SURRENDER The Company has the right to suspend or
delay the date of any Surrender payment
from the Variable Account for any
period:
1. When the New York Stock Exchange is
closed;
2. When trading on the New York Stock
Exchange is restricted;
3. When an emergency exists as a result
of which: (a) disposal of securities
held in the Variable Account is not
reasonably practicable; or (b) it is
not reasonable practicable to fairly
determine the value of the net assets
of the Variable Account;
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4. During any other period when the
Securities and Exchange Commission,
by order, so permits for the
protection of security holders; or
5. When the request for Surrender is not
made in writing.
Rules and regulations of the Securities
and Exchange Commission will govern as
to whether the conditions set forth in
numbers 2, 3, and 4 above exist.
The Company further reserves the right
to delay payment of a total surrender of
Fixed Account Contract Value for up to
six months in those states where
applicable law requires the Company to
reserve such right.
ANNUITIZATION PROVISIONS
GENERAL All of the provisions within this
section are subject to the restrictions
set forth in the Section entitled "Death
of Contract Owner", and "Death of
Annuitant".
ANNUITIZATION This is the process of purchasing an
annuity according to the option
selected, during the payout phase of the
Contract. As of the Annuity Commencement
Date, the Contract Value is surrendered
and applied to the purchase rate then in
effect for the option selected. The
purchase rates for options set forth
under this Contract will be determined
on a basis not less favorable than the
1971 Individual Annuity Mortality Table
(set back one year) with minimum
interest at 3.5%. The purchase rates
will not be less favorable than those
offered by the Company at the time of
Annuitization on a Single Premium
Immediate Annuity for the same age, sex,
and Annuity Payment Option. The rates
shown in the Annuity Tables are
calculated on this guaranteed basis.
Annuitization is irrevocable once
payments have begun.
ANNUITY COMMENCEMENT DATE Such date: (1) must be the first day of
a calendar month; and (2) must be at
least two years after the Date of Issue.
The Annuity Commencement Date may not be
later than the first day of the first
calendar month after the Annuitant's
75th birthday, unless a later date has:
(1) been requested by the Contract
Owner; and (2) approved by the Company.
This date is selected by the Owner at
the time of application. Any applicable
premium taxes not already deducted will
be deducted from the Contract Value at
this time. The remaining Contract Value
will then be applied to the Annuity
Payment Option selected by the Owner.
CHANGE OF ANNUITY COMMENCEMENT DATE The Owner may change the Annuity
Commencement Date. A change of Annuity
Commencement Date must be made prior to
the Annuity Commencement Date and by
written request. The request must be
received at the Home Office prior to the
new Annuity Commencement Date. The date
to which such a change may be made must
be the first day of a calendar month.
CHANGE OF ANNUITY PAYMENT OPTION The Owner may change the Annuity Payment
Option prior to the Annuity Commencement
Date. A change of the Annuity Payment
Option must be made by written request
and must be received at the Home Office
prior to the Annuity Commencement Date.
After a change of Annuity Payment Option
is received at the Home Office, it will
become effective as of the date it was
requested. A change of Annuity Payment
Option will not apply to any payment
made or action taken by the Company
before it was received.
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17
ANNUITY PAYMENT OPTIONS One Annuity Payment Option or a
combination of Annuity Payment Options
may be selected. Any Annuity Payment
Option not set forth in the Contract
which is satisfactory to both the
Company and the Annuitant may be
selected.
SUPPLEMENTARY AGREEMENT A Supplementary Agreement will be issued
within 30 days following the Annuity
Commencement Date. The Supplementary
Agreement will set forth the terms of
the Annuity Payment Option selected.
FREQUENCY/AMOUNT OF PAYMENTS Payments will be made based on the
payment option selected and frequency
selected. However, if the net amount to
be applied at the Annuity Commencement
Date is less than $500, the Company has
the right to pay such amount in one lump
sum.
If any payment provided for would be or
becomes less than $20, the Company has
the right to change the frequency of
payment to an interval that will result
in payments of at least $20.
FIXED ANNUITY PROVISIONS A Fixed Annuity is an annuity with
level payments which are guaranteed by
the Company as to dollar amount during
the annuity payment period. At the
Annuity Commencement Date, the Contract
Value will be applied to the applicable
Annuity Table. This will be done in
accordance with the Annuity Payment
Option selected.
VARIABLE ANNUITY A Variable Annuity is an annuity with
payments which: (1) are not
pre-determined or guaranteed as to
dollar amount; and (2) vary in amount
with the investment experience of the
Variable Account.
DETERMINATION OF FIRST VARIABLE At the Annuity Commencement Date, the
ANNUITY PAYMENT Variable Account Contract Value will be
applied to the applicable Annuity Table.
This will be done in accordance with the
Annuity Payment Option selected. The
Annuity Tables are based on the 1971
Individual Annuity Mortality Table (set
back one year) with interest at 3.5%.
ANNUITY UNIT VALUE An Annuity Unit is used to calculate the
value of annuity payments. The value of
an Annuity Unit for each Sub-Account was
arbitrarily set at $10 when the first
mutual funds were bought. The value for
any later Valuation Period is found as
follows:
1. The Annuity Unit Value for each
Sub-Account for the last prior
Valuation Period is multiplied by the
Net Investment Factor for the
Sub-Account for the Valuation Period
for which the Annuity Unit Value is
being calculated.
2. The result is multiplied by an
interest factor. This is done to
neutralize the Assumed Investment
Rate of 3.5% per year, which is built
into the Annuity Table.
VARIABLE ANNUITY PAYMENTS Variable Annuity payments after the
AFTER THE FIRST first vary in amount. The payment amount
changes with the investment performance
of the Sub-Accounts within the Variable
Account. The dollar amount of such
payments is determined as follows:
1. The dollar amount of the first
annuity payment is divided by the
value of an Annuity Unit as of the
Annuity Commencement Date. This
result establishes the fixed number
of Annuity Units for each monthly
annuity payment after the first. This
number of Annuity Units remains fixed
during the annuity payment period.
2. The fixed number of Annuity Units is
multiplied by the Annuity Unit Value
for the Valuation Period for which
the payment is due. This result
establishes the dollar amount of the
payment.
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The Company guarantees that the dollar
amount of each payment after the first
will not be affected by variations in
expenses or mortality experience.
ANNUITY PAYMENT OPTIONS
GENERAL All annuity payments will be mailed
within 10 working days of the first of
the month in which they are scheduled to
be made.
LIFE ANNUITY The amount to be paid under this option
will be paid during the lifetime of the
Annuitant. Payments will cease with the
last payment due prior to the death of
the Annuitant.
JOINT AND LAST SURVIVOR ANNUITY The amount to be paid under this option
will be paid and continued during the
lifetimes of the Annuitant and
designated second person. Payments will
continue as long as either is living.
LIFE ANNUITY WITH 120 OR 240 PAYMENTS The amount to be paid under this option
GUARANTEED will be paid during the lifetime of the
Annuitant. A guaranteed period of 120 or
240 months may be selected. If the
Annuitant dies prior to the end of this
guaranteed period, the Beneficiary may
choose to continue receiving payments
until the end of the guaranteed period,
or receive the commuted value of the
remaining guaranteed payments in a lump
sum. Such lump sum payment will be equal
to the present value of the remaining
guaranteed payments to which the
Annuitant would have been entitled had
he not died. Any lump sum payment will
be computed as of the date on which
proof of the death of the Annuitant is
received at the Home Office and computed
at an assumed investment rate which is
equal to the rate used to determine
annuity payments, according to the
Annuity Tables, in effect on the Annuity
Commencement Date.
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19
ANNUITY TABLES
JOINT AND SURVIVOR MONTHLY ANNUITY PAYMENTS PER $1,000 APPLIED
ANNUITANT'S AGE LAST BIRTHDAY
FEMALE AGE
50 55 60 65 70
--------- --------- --------- --------- -----
MALE AGE 50 $3.91 $4.07 $4.21 $4.34 $4.44
55 4.00 4.20 4.41 4.59 4.76
60 4.08 4.32 4.59 4.86 5.12
65 4.42 4.75 5.12 5.50
LIFE ANNUITY MONTHLY ANNUITY PAYMENTS PER $1,000 APPLIED
MALE FEMALE
GUARANTEED PERIOD GUARANTEED PERIOD
ANNUITANT'S ANNUITANT'S
ATTAINED ATTAINED
AGE LAST 120 240 AGE LAST 120 240
BIRTHDAY NONE MONTHS MONTHS BIRTHDAY NONE MONTHS MONTHS
-------- ---- ------ ------ -------- ---- ------ ------
40 $3.99 $3.98 $3.91 40 $3.73 $3.72 $3.70
41 4.05 4.03 3.95 41 3.77 3.76 3.73
42 4.11 4.08 4.00 42 3.81 3.80 3.77
43 4.16 4.14 4.04 43 3.86 3.85 3.81
44 4.23 4.20 4.09 44 3.91 3.89 3.85
45 4.29 4.26 4.14 45 3.96 3.94 3.89
46 4.36 4.32 4.19 46 4.01 3.99 3.94
47 4.44 4.39 4.24 47 4.06 4.05 3.98
48 4.51 4.46 4.29 48 4.12 4.10 4.03
49 4.59 4.53 4.35 49 4.18 4.16 4.08
50 4.67 4.60 4.40 50 4.25 4.23 4.13
51 4.76 4.68 4.46 51 4.32 4.29 4.19
52 4.85 4.76 4.51 52 4.39 4.36 4.24
53 4.95 4.85 4.57 53 4.47 4.43 4.30
54 5.05 4.93 4.63 54 4.55 4.51 4.36
55 5.15 5.03 4.69 55 4.64 4.59 4.43
56 5.26 5.12 4.75 56 4.73 4.67 4.49
57 5.38 5.22 4.81 57 4.82 4.76 4.55
58 5.50 5.33 4.87 58 4.93 4.85 4.62
59 5.63 5.44 4.93 59 5.03 4.95 4.69
60 5.77 5.55 4.99 60 5.15 5.05 4.76
61 5.91 5.67 5.05 61 5.27 5.16 4.83
62 6.07 5.80 5.11 62 5.39 5.27 4.90
63 6.23 5.93 5.17 63 5.53 5.39 4.97
64 6.41 6.06 5.23 64 5.67 5.52 5.04
65 6.60 6.21 5.28 65 5.83 5.66 5.11
66 6.81 6.36 5.34 66 6.00 5.80 5.18
67 7.03 6.51 5.38 67 6.19 5.95 5.24
68 7.26 6.67 5.43 68 6.39 6.12 5.30
69 7.51 6.84 5.47 69 6.61 6.29 5.36
70 7.79 7.01 5.51 70 6.85 6.46 5.41
71 8.08 7.19 5.54 71 7.11 6.65 5.46
72 8.40 7.36 5.57 72 7.39 6.85 5.50
73 8.74 7.54 5.60 73 7.70 7.05 5.54
74 9.10 7.73 5.62 74 8.03 7.25 5.57
75 9.50 7.91 5.64 75 8.40 7.46 5.59
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21
NATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY
--------------------------------------------------------------------------------
INDIVIDUAL FLEXIBLE PURCHASE PAYMENT DEFERRED VARIABLE ANNUITY,
NON-PARTICIPATING.
--------------------------------------------------------------------------------
22
NATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY
(FORMERLY FINANCIAL HORIZONS LIFE INSURANCE COMPANY)
ENDORSEMENT
THIS ENDORSEMENT IS ATTACHED TO AND MADE A PART OF CONTRACT FHL-23-7
AND ANY STATE SPECIFIC VERSION OF THE CONTRACT.
The name of the Separate Investment Account referenced on the Data Page is
changed to Nationwide VA Separate Account-C.
The "Death of Contract Owner" section of the Contract is modified by adding the
following sentence to the last paragraph of the section:
"If the Contract Owner is not an individual, the death of the
Annuitant (or a change of the Annuitant) will result in a
distribution pursuant to these rules, regardless of whether a
Contingent Annuitant was named."
The "General Death Benefit Provision" section of the Contract is modified. The
first sentence of the second paragraph is modified to read:
"The amount of the Death Benefit will be the greatest of: (1) the
sum of all purchase payments, less surrenders, (2) the Contract
Value, or (3) the Contract Value as of the most recent five year
Contract Anniversary, less any amounts surrendered since the most
recent five-year Contract Anniversary."
23
NATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY
TWO NATIONWIDE PLAZA
P.O. BOX 182008
COLUMBUS, OHIO 43218-2008
ENDORSEMENT
The Contract to which this Endorsement is attached and made a part of is hereby
modified with the revisions of any "Contract Maintenance Charge" provisions
specified below. Nothing contained herein shall be construed as superseding any
provisions of the Contract to which this Endorsement is attached, unless
specifically indicated to the contrary.
General Provisions
------------------
To the extent that the Charge section under the GENERAL PROVISIONS is
inconsistent with the provision set forth below, the provision is hereby
modified in accordance with the following:
CHARGES
-------
The Company deducts a charge for the administration of the Contract. This
charge is designed only to reimburse the Company for any expense incurred
that relates to the administration of the Contract. The Company will
monitor this charge to ensure that it does not exceed any accumulated
expense. The Contract Administration Charge is assessed daily through the
unit value calculation, equal to an annual rate of [0.05%].
Surrender Provisions
--------------------
To the extent that the "General Surrender Provisions" and "Surrender Value"
sections under the SURRENDER PROVISIONS are inconsistent with the provisions set
forth below, such provisions are hereby modified in accordance with the
following:
GENERAL SURRENDER PROVISIONS
----------------------------
4. When written application and the Contract are received, the Company
will surrender a number of Variable Account Accumulation Units and an
amount from the Fixed Account needed to equal: (a) the dollar amount
requested; plus (b) any Contingent Deferred Sales Charge which applies.
SURRENDER VALUE
---------------
The Surrender Value is the amount that will be paid if the full Contract
Value is surrendered. The Surrender Value at any time will be:
1. The Contract Value; less
2. Any Contingent Deferred Sales Charge which applies.
--- ---
| Secretary President |
| |
| |
24
AMENDATORY ENDORSEMENT
Attached to and made a part of this Contract issued by
NATIONWIDE LIFE AND ANNUITY INSURANCE COMPANY
ONE NATIONWIDE PLAZA COLUMBUS, OHIO 43216
PO BOX 16609
COLUMBUS, OHIO 43216-6609
This Endorsement restates and clarifies provisions of the Contract to which it
is attached. Notwithstanding any provisions of the Contract to the contrary, the
following provisions shall apply:
1. THE FOLLOWING IS HEREBY ADDED TO THE DEFINITION OF ANNUITANT:
"The Annuitant must be age [80] or younger at the time of Contract issuance
unless the Company has approved a request for an Annuitant of a greater age."
2. THE FOLLOWING IS XXXXXX ADDED TO THE DEFINITION OF CONTRACT OWNER:
"The Contract Owner must be age [80] or younger at the time of Contract issuance
unless the Company has approved a request for a Contract Owner of a greater
age."
3. THE SECOND SENTENCE OF THE INITIAL PURCHASE PAYMENT SECTION IS HEREBY DELETED
AND REPLACED WITH THE FOLLOWING:
"The Initial Purchase Payment may not be less than [$2,000] for Non-Qualified
Contracts."
4. THE FIRST PARAGRAPH OF THE SURRENDERS WITHOUT CHARGE SECTION IS HEREBY
DELETED AND REPLACED WITH THE FOLLOWING:
"Once each year, starting with the first Purchase Payment Year, the Contract
Owner may surrender without a Contingent Deferred Sales Charge, an amount equal
to [10%] of the Purchase Payments at the time of surrender. This free withdrawal
privilege is cumulative; that is, free amounts not taken during any given
contract year can be taken as free amounts in subsequent years."
25
5. THE SECOND PARAGRAPH DESCRIBING THE AMOUNT OR THE VALUE OF THE DEATH BENEFIT
UNDER THE GENERAL DEATH BENEFIT PROVISIONS IS HEREBY DELETED AND REPLACED WITH
THE FOLLOWING:
"If the Annuitant dies prior to his [85] th birthday, the amount of the Death
Benefit will be the greater of 1. the Contract Value, 2. the total of all
purchase payments made to the contract, less an adjustment for amounts
surrendered, or 3. the Contract Value as of the most recent five year Contract
Anniversary, less an adjustment for amounts surrendered since that five year
anniversary. The amount of the Death Benefit will be limited to the Contract
Value if the Annuity Commencement Date is deferred beyond age [85] of the
Annuitant and the Annuitant dies after attaining such age."
Any adjustment for amounts surrendered will reduce 2 and 3 in the same
proportion that the Contract Value was reduced on the date(s) of the partial
surrender.
Except for the above mentioned amendments nothing else is changed in the
Contract.
----- -----
/s/ /s/
----- -----
SECRETARY PRESIDENT
